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MARKUP OF H.R. 829 AND H.R. 181

TUESDAY, FEBRUARY 7, 2016

House of Representatives,

Subcommittee on Health,

Committee on Energy and Commerce

Washington, D.C.

The subcommittee met, pursuant to call, at 10:00 a.m., in

Room 2123 Rayburn House Office Building, Hon. Michael Burgess

[chairman of the subcommittee] presiding.

Present: Representatives Burgess, Guthrie, Barton, Shimkus,

Murphy, Blackburn, McMorris Rodgers, Lance, Griffith, Bilirakis,

Long, Bucshon, Brooks, Mullin, Hudson, Collins, Carter, Walden,

Upton (ex officio), Green, Engel, Schakowsky, Butterfield,

Matsui, Castor, Sarbanes, Lujan, Schrader, Kennedy, Cardenas,

Eshoo, DeGette, and Pallone (ex officio).

Staff present: Grace Appelbe, Staff Assistant; Will Batson,

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Legislative Clerk, Energy and Power; Ray Baum, Staff Director;

Elena Brennan, Legislative Clerk, Oversight and Investigations;

Adam Buckalew, Professional Staff, Health; Karen Christian,

General Counsel; Jordan Davis, Director of Policy and External

Affairs; Paige Decker, Executive Assistant and Committee Clerk;

Paul Edattel, Chief Counsel, Health; Blair Ellis, Digital

Coordinator/Press Secretary; Adam Fromm, Director of Outreach and

Coalitions; Giulia Giannangeli, Legislative Clerk, Digital

Commerce and Consumer Protection/Environment; Caleb Graff,

Professional Staff, Health; Jay Gulshen, Legislative Clerk,

Health; Zach Hunter, Director of Communications; Peter Kielty,

Deputy General Counsel; Katie McKeough, Press Assistant; Kristen

Shatynski, Professional Staff Member, Health; Jennifer Sherman,

Press Secretary; Hamlin Wade, Special Advisor, External Affairs;

Luke Wallwork, Staff Assistant; Gregory Watson, Legislative

Clerk, Communications and Technology; Elizabeth Ertel, Minority

Office Manager; Tiffany Guarascio, Minority Deputy Staff Director

and Chief Health Advisor; Dan Miller, Minority Staff Assistant;

Olivia Pham, Minority Health Fellow; Rachel Pryor, Minority

Health Policy Advisor; Tim Robinson, Minority Chief Counsel;

Samantha Satchell, Minority Policy Analyst; Matt Schumacher,

Minority Press Assistant; Andrew Souvall, Minority Director of

Communications, Outreach and Member Services; and C.J. Young,

Minority Press Secretary.

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Mr. Burgess. The subcommittee will now come to order. The

chair recognizes himself for five minutes for an opening

statement.

Medicaid was established to serve the most vulnerable

individuals in their time of greatest need. As a practicing

physician for over 30 years, I have a first-hand understanding

of the important roles that this safety-net program serves. As

the costs of the program grow, it is more important than ever to

ensure that Medicaid spending stays on a sustainable path.

We are here today to vote on two common-sense proposals that

would do just that, prioritize care for the vulnerable patients

that Medicaid is intended to serve. Both of these bills are

focused on narrow issues and they have been introduced in prior

sessions of Congress. In fact, both have been considered twice

in legislative hearings by this subcommittee, first, in September

of 2015, and again last week. We are committed to crafting policy

in an open and inclusive manner. We are committed to working

hard. We are committed to collaboration and the scrutiny of the

American people.

The committee will continue to welcome constructive

suggestions to improve these bills before each is advanced to the

full committee for markup.

First, we will consider H.R. 829, a bill introduced by

Representative Upton to clarify the treatment of lottery winnings

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and other lump sum income for the purposes of income eligibility

under the Medicaid program. This common-sense proposal would

require states to consider such income as if it were obtained over

multiple months for the purposes of determining the modified

adjusted gross income for Medicaid or Children's Health Insurance

Program eligibility. I hope we can all agree that Powerball

lottery winners should not be eligible to receive Medicaid which

is precisely the problem in current law that this bill from Mr.

Upton would fix.

Secondly, we will consider H.R. 181, close annuity loopholes

in Medicaid Act, as introduced by Representative Mullin. This

bill would close the gap in current law that allows married

individuals to increase the amount of assets a community spouse

may retain above state and federal maximums. This bill would help

prevent cost shifting from wealthy individuals to the Medicaid

program and ensure that the program is available to those who are

most in need of its assistance.

Both of these bills would reduce federal and state Medicaid

spending by hundreds of millions of dollars, freeing up resources

that could be directed towards specific patient populations or

areas of need. We all agree that it is important to secure care

and to keep our commitment to vulnerable Americans. It is my hope

that we can work together, that we can work on a bipartisan basis

to make Medicaid more sustainable. I hope that we can begin by

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taking these small steps to put Medicaid spending on a sustainable

path. I am confident that we can continue to advance bills

through an open and inclusive process to protect and empower

patients.

And I yield back the balance of my time and recognize the

ranking member of the subcommittee, Mr. Green, for five minutes

for your opening statement, please, sir.

Mr. Green. Thank you, Mr. Chairman. Medicaid is a lifeline

and a safety net for more than 74 million Americans who depend

on the coverage. One in 5 Americans receive health coverage from

Medicaid, including 12 million people who now have health

insurance thanks to the Affordable Care Act expansion of Medicaid

for low-income adults. It is the primary health insurer for more

than 10 million Americans with disabilities, financing more than

half of all births and is the main source of long term care

coverage. One in seven seniors is on Medicaid. Seventy percent

of all nursing home residents rely on this program.

We are here to mark up two bills that were considered by this

subcommittee last week, H.R. 181 and H.R. 829. Unfortunately,

I can't support either bill. Instead of strengthening the

program, these bills would generate small savings by delaying or

denying coverage or eliminating eligibility for some Medicaid

beneficiaries and doing nothing to substantially improve the

program.

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H.R. 181 requires that half of the income produced by

Medicaid complying annuities that a spouse living in a community

receives be considered income for the purposes of their spouse's

eligibility for the long-term care.

H.R. 829 would require states to count a one-time lump sum

payment that an individual receives as though it were income that

the individual is receiving anywhere between two months and ten

years after actually getting the payment.

Both bills are predicated on the false idea that there are

large numbers of unworthy beneficiaries taking advantage of

Medicaid. You are always going to be able to find a new examples

of bad actors when talking about a program that insures more than

74 million Americans each year.

While there may be a handful of wealthy individuals using

annuities to shield income, or an individual who had won the

lottery and did not immediately notify their state Medicaid agency

and enrolled in private coverage, these are extreme outliers and

not the basis for which we should be considering ways to improve

and strengthen Medicaid.

The bills are part of a larger effort to chip away at the

program and advance the false narrative that Medicaid program is

not financially sound and therefore must be cut. These claims

are both misleading and over simplistic. Legislative proposals

that immediately delay or deny coverage under guise of

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strengthening the program are imprudent and should be rejected.

Our goal should be to ensure that every American has a consistent

source of health insurance with regular access to care. That is

why the Affordable Care Act removed asset testing and Medicaid

for most groups and streamlined eligibility across the nation.

There are ways we can work together and strengthen Medicaid.

For example, for several Congresses, my colleague and fellow

Texan, Joe Barton and I have introduced bipartisan legislation

to provide 12 months continuous coverage for beneficiaries in

Medicaid and CHIP, aligning the program with private insurance

practice. This would reduce the churn, lower overhead, and

administrative costs and ensure that beneficiaries maintain the

continuity of care which keeps chronic illnesses under control

and patients out of the most costly emergency room.

Last Congress and the Congresses before, we worked together

to improve the Medicaid program. I stand ready to work with

anyone on proposals that would meaningfully strengthen coverage,

program integrity, and access to Medicaid.

And I thank you, Mr. Chairman. I yield back my time.

Mr. Burgess. The gentleman yields back. The chair thanks

the gentleman. The chair recognizes the gentleman from Oregon,

Mr. Walden, chairman of the full committee, for five minutes for

an opening statement.

Mr. Walden. Thank you very much, Mr. Chairman. I am

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delighted to be here today. This is our first markup of this

Congress and it opens a new chapter and opportunity for us to lead.

It is a big opportunity, one we are not taking lightly. Our goal

is straight forward, to modernize America's healthcare laws by

making what is best for patients our top priority.

And indeed, we do start today by going after bad actors, not

ignoring them, by going after people who shield their income and

deprive people who need help in Medicaid the services that they

need.

As the committee of jurisdiction, we are focused on ways to

strengthen, improve, and modernize the Medicaid program. We all

agree Medicaid is a critically important safety net for millions

of our citizens, low-income adults, children, pregnant women, the

elderly, or those who are blind or have disabilities. We are

committed to protecting these patients and to supporting

innovative patient-center solutions at the state and local

levels, particularly as we work to ensure the solvency of this

program.

We want to prioritize federal funding to make sure that those

most in need of medical services in our communities, get better

quality and affordable care.

Today, we continue our work with those goals in mind starting

with bills authored by former Chairman Fred Upton and

Representative Markwayne Mullin. These bills will empower

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states with more flexibility. They will help prioritize the

Medicaid program for the most vulnerable. And this important

flexibility and reform are exactly what our governors are begging

us to give them.

Just a couple of weeks ago, I had the opportunity to meet

and listen to more than a dozen governors from around the country.

Their requests were as clear as they were common. They said give

states the flexibility to care for our people in ways we know work.

That is what they want to do.

The bills we are considering today originated from our

members who listened to their constituents and their leaders from

back home who called on Congress to do more to root out waste,

fraud, and abuse. Over the last 14 years, the Government

Accountability Office has put Medicaid on the list of high risk

federal programs.

Last week, before our Oversight and Investigations

Subcommittee, the Government Accountability Office, and the

Office of Inspector General both reminded us of how a lack of data

and transparency impedes their work. And they just recently

issued their report, the GAO did, confirming their investigation

and what they found.

We need to act. Today's common sense proposals close

loopholes. They root out abuses and bad actors. They target

savings to help patients most in need. This is where you make

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real serious choices that affect the people in our districts by

rooting out bad actors and people who shield their income so that

the taxpayer money is actually there to help people who are most

in need. That is what these bills do.

Know that these are just the first and they are small steps,

but they are steps forward in a journey. In the weeks and months

ahead, we will actively work to improve the healthcare choices

and the affordability of that healthcare for all patients.

Today's bills represent only a fraction of the work we need to

do, but they are an excellent start to our step-by-step approach

to improving our healthcare system for all Americans. And with

that, Mr. Chairman, I yield back the balance of my time.


the gentleman. The chair now recognizes the gentleman from New

Jersey, ranking member of the full committee, Mr. Pallone for five

minutes for your opening statement, please.

Mr. Pallone. Thank you, Mr. Chairman. My opinion on both

pieces of legislation that we are considering today has not

changed from last week. I can't support policies that limit

eligibility and delay coverage and do not strengthen the Medicaid

program for beneficiaries. Medicaid is simply too important for

too many people. These bills merely chip away at the program

around its edges, making no meaningful improvements.

In 2016, over 97 million Americans depended on Medicaid at

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some point during that year. That is our nation's kids, the

disabled, our seniors, and hard-working Americans who simply need

the safety net to make life better for their families. It is

undeniable that Medicaid coverage pays us back as a society

tenfold. And that is why we must improve and strengthen

Medicaid's coverage provisions and not kick people off in the name

of integrity.

My Republican colleagues say they are strengthening

Medicaid, but that is simply not the case. After all, they remain

committed to repealing the Affordable Care Act's Medicaid

expansion provisions, taking healthcare away from millions and

shifting trillions of dollars on to our states by gutting the

financing structure of the Medicaid program.

Now H.R. 181 would count half of the income that a spouse

receives from an annuity as income for purposes of the other

spouse's eligibility for Medicaid long term care. While there

may be some examples of extremely wealthy individuals using

annuities in their spouse's name to shield income, the reality

is that rather than hitting the wealthiest among us, this bill

would likely most impact the financial security of hard-working

spouses.

Moreover, we currently have no long term care insurance in

this country. And until we are ready to have a discussion about

improving options in the long term care insurance marketplace,

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I am concerned about any changes to Medicaid eligibility that

would make it harder for working people to access the care that

they need.

The other bill, H.R. 829, would limit Medicaid coverage for

people that receive the one time lump sum payment of $80,000 or

more for anywhere from two months to ten years. Despite what

Republicans say, this is not a bill about lottery winners and

millionaires. If Republicans truly wanted to kick millionaires

off of Medicaid, this bill would look very different. My

Republican colleagues say they are strengthening Medicaid by

removing or excluding certain people from the program, claiming

that it will allow for more resources to go towards others. This

is meaningless. This is a meaningless approach to resource

management. There is no evidence to suggest that some

beneficiaries take away resources from others or that excluding

some beneficiaries are going to benefit others. Nor did it

truly strengthen the Medicaid program. We should expand

coverage, protect against fraud, and implement advanced delivery

system reform.

I would like to remind my colleagues that the Affordable Care

Act did just that. If Republicans really wanted to strengthen

the Medicaid program, I stand ready to build on those efforts.

But I will not support policies that simply chip away at the

coverage that so many millions of people depend on. I yield back

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unless someone else wants some time. I guess not.

I yield back, Mr. Chairman.


the gentleman. The chair now recognizes the gentleman from

Michigan, the Chairman Emeritus of the full Committee, Mr. Upton,

three minutes for your opening statement, please.

Mr. Upton. Thank you, Mr. Chairman. I want to say just

a quick word regarding the bill that I introduced, H.R. 829,

Prioritizing the Most Vulnerable Over Lottery Winners Act of 2017.

So under Medicaid regulations, income received as a lump sum,

such as lottery winnings is counted as income only in the month

that it is received. And as a result, states are effectively not

allowed to disenroll lottery winners from Medicaid. This forces

taxpayers to bear the burden of paying the healthcare benefits

for individuals who no longer require assistance.

H.R. 829 will close the loophole by requiring states to count

monetary winnings from lotteries of $80,000 or more, not $2 or

$4 winners or $6, but $80,000 or more as if they were obtained

over multiple months even if obtained in a single month.

This common-sense solution would alter how Medicaid

eligibility is determined for those lucky enough to hit that big

cash windfall by playing the lottery, while continuing to

prioritize the low-income population that the program is meant

to assist, the most vulnerable. In fact, the bill has been

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amended from previous iterations to include changes suggested by

our committee's minority.

Moreover, this legislation is estimated to save taxpayers

hundreds of millions of dollars. The legislation will ensure

that this money is spent on those who need it most, as opposed

to those who strike it big.

So I want to say, too, I will be offering a technical

amendment that will allow more time for state implementation. It

will allow, but not require a hardship exemption, noting that a

state can do that through an 1115 waiver and clarifying the

winnings test does apply to the individual's spouse.

And with that, Mr. Chairman, I yield back the balance of my

time.


the gentleman. The chair recognizes the gentlelady from

California, Ms. Matsui, for three minutes for an opening

statement, please.

Ms. Matsui. Thank you, Mr. Chairman. The Medicaid program

is a critical foundation for healthcare services, particularly

for children, seniors, and those with mental illness. The impact

of Medicaid in our nation's families cannot be overstated.

The proposals my Republican colleagues have put forth would

impose arbitrary caps on Medicaid. This ties the hands of state

leaders and poses a real threat to families who rely upon Medicaid

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now or may need it in the future.

We can't force states to choose between covering seniors or

children or the mentally ill. In California, two of five children

are enrolled in Medi-Cal program which is our Medicaid. As a

result of Medi-Cal coverage, these children have access to well

child checkups and prevention and treatment that keeps them

healthy. This means that children can stay in school, learn, and

grow.

Medicaid gives millions of kids a healthy start in life and

opportunities to thrive. Medicaid has also expanded access to

mental health prevention and treatment services for millions more

Americans. Medicaid means access to depression screenings, and

hospital and community services during a mental health crisis.

And nearly two million Americans have gained access to substance

abuse treatments including for opioid abuse under the ACA's

Medicaid expansion.

If we were to repeal the Medicaid expansion, we would go

backwards, and once again, leave our nation's mentally ill out

in the cold.

Lastly, three in five people who live in nursing homes in

California are on Medicaid. We don't have a financing system for

long-term services and support in this country and Medicaid fills

that gap. Beneficiaries of a Medicaid program are struggling to

make ends meet. This means living on less than $30,000 per year

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for a family of three. These are not millionaire lottery winners.

Eighty percent of Medicaid enrollees in California are

families with someone who is working. Without Medicaid, these

families might have to choose between seeing a doctor and putting

food on the table. The bills before us today do nothing to address

the real healthcare challenges our constituents are facing.

Medicaid works and we should strengthen it and not limit coverage

and propose ideological cuts.

Thank you and I yield back.

Mr. Burgess. The chair thanks the gentlelady. The

gentlelady yields back. The chair recognizes the gentlelady from

Tennessee, Mrs. Blackburn, three minutes for opening statement,

please.

Mrs. Blackburn. Thank you, Mr. Chairman and I am so pleased

that we are moving forward in a manner that is going to clean up

our Medicaid program to bring transparency, to bring

accountability, and to provide clarity. And Chairman Walden

mentioned the meeting we had with the governors. These are three

things they pointed out to us that they want. Clarity. They want

to have transparency. They want accountability because they know

it is important to have a Medicaid delivery system that is going

to work.

The more they have the ability to work within that, to meet

the needs of their individuals in their states that are Medicaid

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enrollees, the better outcomes we will see, the better access to

affordable healthcare you will see. And isn't that what we want

for everyone to have access to affordable healthcare?

I am so pleased that we are beginning with these bills that

will bring some accountability to the process. I urge my

colleagues to support the legislation that is before us and Mr.

Chairman, I yield back the balance of my time.


gentlelady yields back. The chair will yield three minutes to

the gentlelady from Florida, Ms. Castor, for an opening statement,

please.

Ms. Castor. Thank you, Mr. Chairman. Members, we are one

month into the new Congress and American families are on edge

because the Republican majority and the new President has left

them with a lot of uncertainty and a couple of impressions. One,

there is an overwhelming Republican zeal to repeal the Affordable

Care Act without anything to replace it.

Now President Trump says he has got a fabulous plan. It is

going to be a wonderful plan where everyone has insurance. The

problem is there is no plan. We haven't seen a plan. And in fact,

what my Republican colleagues are saying on time tables, they are

all over the map. Is it this month? Is it in March? Is it next

year some time? Is it by the end of the summer? And this is

causing great uncertainty among our families and everyone who

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relies on the health sector, for their job, for their care. It

is doing particular damage to the individual market under

healthcare.gov. Not only did the new Trump administration say we

are just not going to promote healthcare.gov and sign ups, but

all of this uncertainty now is weighing upon not just families,

but health insurers and providers that don't know the way forward

and it is just not right.

The other impression they have left is really for our

neighbors who rely on skilled nursing. If you have a family

member with Alzheimer's or a disability or almost half of

America's children that rely on Medicaid services, there also is

great uncertainty because the Republican budgets and what they

have said over the past few years is to the contrary, not to

strengthen Medicare, that is a euphemism, strengthen Medicare,

because what they plan to do and what is being talked about is

to pull the rug out from under our families that rely on Medicaid.

Medicaid currently functions as the only long term care

insurance in this country, yet instead of having a real

conversation about financing long-term care, Republicans want to

make it harder for working middle class, spouses, to remain

financially secure in the face of overwhelming and insurmountable

long term care cost.

We are going to stand up and fight these cuts and what it

will do to American families. You can bet on that. But we need

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those families to help us and to stand up and say what Medicaid,

Medicare, the Affordable Care Act means to them. I am hearing

them. I trust that the rest of you are hearing them as well. I

yield back.

Mr. Burgess. The gentlelady yields back. The chair thanks

the gentlelady. The chair recognizes the gentleman from

Virginia, Mr. Griffith, three minutes for an opening statement,

please.

Mr. Griffith. Thank you very much, Mr. Chairman. I do

appreciate it. I support the concept of both bills, but I do

believe we need to resolve an unintended consequence inside of

H.R. 181 dealing with annuities and I am working with staff to

try to come up with the proper language and so forth and we will

hopefully have that ready for the full committee.

And what it deals with is the community spouse annuity

section because when you have a community spouse, most of the time

this is going to make sense because the annuity would have been

purchased with marital assets. But there are going to be

situations where an annuity is purchased with non-marital assets.

In Virginia parlance that would mean that the money was a

sole separate equitable estate of the community spouse. This can

happen several ways and probably some I haven't thought of, but

it can happen because an annuity may be purchased by a wealthy,

elderly parent for a child within the 60-month look back because

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we don't always know. We always think about it being somebody

who is older, but that spouse could be somebody who is younger,

who unfortunately has a stroke or something like that and the

parent has bought an annuity for their child, not the

institutionalized spouse, but the community spouse. That is

separate property under the laws at lease of the Commonwealth of

Virginia.

Likewise, an annuity could be purchased out of funds

considered separate by the rules of the state because when you

have a later marriage in life, a lot of times those folks come

in with assets and the property that they had prior to the marriage

is, in fact, separate property.

Last, but not least, it could actually have been anticipated

that a purchase would be made out of separate assets in a

pre-nuptial agreement in that situation.

So here is the dilemma that we have. I fear that

unfortunately and as an unintended consequence that if we don't

change the language, we may actually be encouraging, and in fact,

incentivizing divorce because in each one of those examples I

named, at least in the Commonwealth of Virginia, those assets

would be sole separate property which would be protected in a

divorce action and if they don't get a divorce under this bill,

the Federal Government would be coming in for Medicaid purposes

and taking it for the institutionalized spouse from the community

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spouse. We would like to think that people wouldn't do such

things, but if there is a significant amount of money laying on

the table, I submit to you that they will.

Now I know this was not the intent of the bill and I know

that we can craft language that will make an exception that

recognizes the state laws as regards separate assets. So I look

forward to working with the committee on this and having something

ready for this when we get to the full committee.

Thank you very much and yield back.


the gentleman. The chair now recognizes the gentlelady from

Illinois, Ms. Schakowsky, three minutes for an opening statement,

please.

Ms. Schakowsky. I oppose the two bills we are considering

today, both of which would only make it harder for eligible

individuals to receive Medicaid benefits and would harm low income

and middle class families.

First, despite claims that H.R. 829 will target lottery

winners and millionaires, the truth of the matter is that this

legislation would kick low-income individuals off Medicaid. If

this legislation were truly intended to target lottery winners

and millionaires, then why are we considering a bill that would

kick people off Medicaid for even very modest lump sums that are

neither lottery winnings nor would make any individual a

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millionaire.

Given that many of these families live off very little income

to begin with, any additional funds will likely be used to pay

off debts, help send kids to college or pay their rent or mortgage.

The last thing they need to be worried about is losing access to

health insurance.

The second bill we are considering, H.R. 181, would target

middle-income families who are struggling to afford the cost of

long-term care for their loved ones. The decision to place a

spouse in institutional long-term care or the process to get a

loved one into long-term home and community-based care is

incredibly difficult, both emotionally and financially. These

are people whose spouses no longer are able to care for themselves

because they have serious life-threatening conditions like

Alzheimer's disease, Parkinson's, or MS. It is beyond

understanding that we would make it harder for those people to

get their spouse the care they need, while also ensuring that they

have enough income to live off of.

Let me remind my Republican colleagues that Medicaid is the

long term care insurance system in this country. There simply

is not another option for low- and middle-income families.

Let me also remind my Republican colleagues that private long

term care insurance still allows insurance companies to

discriminate for preexisting conditions. So individuals with

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MS, Alzheimer's, or other progressive diseases that require

long-term care are often left without access to private insurance,

even if they have the ability to afford it.

I think we can all agree that we should not require someone

to live in poverty if their spouse requires long-term care which

is exactly why we work to prevent spousal impoverishment in the

Affordable Care Act.

And let me just say to the chairman of the full committee,

the reason people are calling their members of Congress now is

not to cut Medicaid, but to not repeal the ACA. And a big part

of that, I believe, is because Medicaid is so important and

particularly for many of our middle class senior citizens who rely

on Medicaid for their long-term care. And I yield back.

Mr. Burgess. The gentlelady's time is expired. The

gentlelady yields back. The chair recognizes the gentleman from

Oklahoma, Mr. Mullin, three minutes for an opening statement,

please.

Mr. Mullin. Thank you, Mr. Chairman, and for my colleague

from Virginia, we will work with you on that. I think we heard

from your staff last night and we will be happy to work with you

and figure out how we can make that happen.

Thank you, Mr. Chairman Burgess, I am glad to see the Health

Subcommittee mark up the Comm. Act today. Affordable healthcare

or Obamacare as it often is referred to has expanded the broken

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Medicaid system and we need to return these services to those who

need it most.

The bills discussed today are two small reforms that start

a broader discussion on Medicaid reform that we need to be having.

I am proud to have worked with my state government to come up with

one solution we can bring to the table.

H.R. 181, the Comm. Act, closes the loophole that some

married couples use to mask their assets. GAO found that some

couples are hiding up to $1 million in annuities. My bill brings

accountability to this financing loophole and counts half the

annuity payments towards Medicaid income threshold.

I look forward to a productive markup today and the passage

of the Comm. Act. by the committee so that we can start to make

Medicaid stronger.

Thank you, Mr. Chairman, and I yield back.


the gentleman. The chair recognizes the gentleman from Maryland,

Mr. Sarbanes, three minutes for an opening statement, please.

Mr. Sarbanes. Thank you, Mr. Chairman. It seems like over

the last couple of weeks we have been focusing in on these tiny

pieces of important, but small, components of the Medicaid program

and trying to go in and upset those and take them apart and so

forth which in the context of what we are facing overall strikes

me as sort of moving deck chairs around on the deck of the Titanic.

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The proposal to repeal the Affordable Care Act, to eliminate

the Medicaid expansion is a proposal of catastrophic proportion.

And I think that is where the focus of the committee ought to be.

And Republicans, of course, have been proposing to completely

repeal the Affordable Care Act and with it the Medicaid expansion

when the Medicaid program has functioned extremely well.

I just wanted to bring to the committee's attention something

I think all of the individual members are experiencing which is

as you move around in your district, we are hearing more and more

about the opioid addiction crisis, the heroin addiction crisis,

the incredible number of overdoses and deaths that are occurring

and that is accelerating almost exponentially across the country.

It is happening, in particular, in districts and communities and

neighborhoods that have been hardest hit in terms of their

economic situation. It is hitting rural areas. It is hitting

urban areas, suburban areas.

The reason I mention that is because oftentimes it is the

Medicaid program which is there to provide treatment services for

the families that are being affected by this addiction crisis.

So if we eliminate the expansion, if we move to the kind of block

granting proposal that we have heard of which would over time

diminish the resources that are available for the Medicaid program

in the state, it is going to pull the rug out, a safety net, a

treatment net, out from under those families that are grappling

26


with this opioid addiction crisis. So I think we need to focus

on the Titanic which is preserving the Affordable Care Act,

preserving the Medicaid expansion, rather than just moving these

deck chairs around as the majority is proposing. With that, I

yield back.


the gentleman. The chair recognizes the gentleman from Georgia,

Mr. Carter, three minutes for an opening statement, please.

Mr. Carter. Mr. Chairman, thank you for convening today's

markup of H.R. 829 and 181.

For many years now, my colleagues on the other side of the

dais have argued that we needed to take a leap of faith, that by

expanding health insurance coverage it would improve health

outcomes and lower costs for the states by giving the uninsured

access to regular and preventive healthcare. The newly insured

would finally gain access to primary care and substitute going

to the emergency room and hospital care for normal office visits.

But what we have seen is just the opposite. We have seen that

the Medicaid expansion that began in 2014 has only grown more and

more problematic for many of our states.

With over 70 million enrollees, Medicaid covers more

Americans than any other insurer. At a minimum, the Federal

Government covers 50 percent of costs, with that share rising to

nearly 75 percent in the poorer states and more than 90 percent

27


for those covered through ACA Medicaid expansions. This amounts

to nearly $350 billion in federal funding for a year.

This morning, we are taking a moment to discuss common-sense

legislation. We are prioritizing the most vulnerable in Medicaid

by closing loopholes that allow others to take advantage of the

system. One bill that would count lottery winnings obtained over

multiple months against a person's eligibility for Medicaid,

preventing individuals with significant financial means from

inappropriately shifting the cost of their care to the Medicaid

program.

A second that would make half of the income generated from

an annuity purchased by a community spouse countable for purposes

of determining an institutionalized spouse's Medicaid

eligibility for long-term care. I ask my colleagues on both sides

to see the fairness in allowing those who are most vulnerable to

be emphasized in Medicaid and close these loopholes.

I urge my colleagues to support the H.R. 829 and H.R. 181

and I yield back the balance of my time.

Mr. Burgess. The chair thanks the gentleman. The

gentleman yields back. The chair recognizes the gentleman from

New Mexico, Mr. Lujan, three minutes for an opening statement,

please.

Mr. Lujan. Mr. Chairman, thank you very much and to all my

colleagues for being here today.

28


Mr. Chairman, I think that we should spend some time talking

about the Republican plan on Medicaid as a whole. I think

oftentimes there are some questions. There was a recent headline

that was sent out and it said something along the lines of a GOP

Medicaid funding proposals could save $150 billion, the analysis

finds. And I see some of my Republicans shaking their head in

agreement with this headline.

What this translates to is $150 billion in federal cuts to

Medicaid. And the analysis further goes on to say that the

Republican plan could increase costs on the obligations of how

we would be sending this to the states, right?

So in using terms of shifting costs to the states, I think

that we need to help define that and decipher that. That means

cutting federal support and the notion of using block grants and

per capita caps. But in the end, this is the closing statement

of the analysis. States may respond to block grants or per capita

cuts by cutting enrollment, limiting benefits, or reducing

payment rates to providers and plans. Now that doesn't sound like

strengthening this program. It sounds like weakening this

program.

So in the end, Mr. Chairman, I am concerned that my Republican

colleagues are using alternative facts to drive their plan, to

cut federal investments in our nation's Medicaid program. And

New Mexico is part of the Affordable Care Act Medicaid expansion.

29


Medicaid is an important safety net, but it grew from more than

a safety net. It grew to a ladder for the middle class. But that

is not what you think if you listen to the right-wing rhetoric.

Medicaid is a health insurance program that fills a vital

role in my state and across the country. Before passage of the

ACA, the number one reason that middle class families declared

bankruptcy, lost their houses, lost their cars, lost everything,

was medical debt. We should not go back to a time when the

difference between middle class and living in poverty is a cancer

diagnosis, the difference between having a house and being

homeless is one bad car accident. Without this ladder, our middle

class will be hurt. Many hard-working families will be at risk

and more people will be uninsured or under insured.

And Mr. Chairman, the other thing I think it is important

to point out with one of these bills is just so that there is an

honest conversation with the American people, rather than the

promise of these bills saving millions of dollars. In Michigan,

where one of these bills was already implemented, the state saved

a mere $400 over the course of almost two years; $400 over 2015

and '16.

Now I am not saying we should fight for every penny, but it

should be clear to the American people that this plan in Michigan

didn't save millions. It saved $400 over a year and a half.

And then Mr. Chairman, there was another article that came

30


out from President Trump about his changes to the Affordable Care

Act. I certainly hope that there is more information shared with

the American people and this committee of jurisdiction over what

these plans are, because there still seems to be this secret safe

that keeps these plans in that we haven't seen.

Thank you very much.

Mr. Burgess. The gentleman's time has expired. The

gentleman yields back. The chair thanks the gentleman. Are

there further opening statements on the majority side?

Are there further opening statements on the minority side?

The gentlelady from California is recognized for three minutes.

Ms. Eshoo. Thank you, Mr. Chairman. I think it is very

important and I think that we do do this, that members pay a great

deal of heed to what their constituents are saying. Now for six

years plus, there has been a mantra like a Greek chorus chanting,

chanting, chanting every day, every week, every month, all year

long, repeal and replace, repeal and replace, repeal and replace,

repeal and replace.

Now somehow we come here and this is not really attached to

reality. People are awakening all over the country. When they

hear the word repeal, they actually are coming to understand what

they have, what they have. And in the Affordable Care Act,

intertwined in it is Medicare, Medicaid, insurance reforms, the

private sector, intricately interwoven into the law.

31


Medicaid is one of the pillars of the Affordable Care Act.

So why wouldn't people turn out? Why wouldn't people turn out?

Now I don't know whether this is part of replacement. I don't

know if this is part of repeal. But it doesn't seem to fit with

really what is going on across the country.

In many congressional districts, people are just turning out

and demanding to know what members are doing and why. And they

are doing that because they are coming to understand that beyond

repeal and replace, love to hate Obamacare, that there are a whole

set of policies that protect them today that didn't protect them

before the law was in place.

So I think we need to widen the lens. I am not so sure what

we are doing here. I don't know if this is part of repeal. I

don't know if this is part of replace. And I have questions about

how this reforms, especially when it comes to the lottery and how

many millionaires and billionaires are abusing Medicaid. I just

-- that is kind of a hard one to swallow, but I think that when

I have time to question the legal counsel that we might be able

to get some of those answers.

I think my colleagues, my Republican colleagues, you are on

a slippery slope. You are on a very slippery slope. Because

healthcare is as personal as it gets. It is as personal as it

gets. And anyone that tries to diminish what helps people in the

care of their bodies, their families, their children, their

32


grandparents, when it comes to Medicaid, 60 percent of Medicaid

goes to nursing homes. Anyone that has dementia with a relative,

that is a very slippery slope. So with that, I yield back. Thank

you.


gentlelady's time has expired. Are there further members on the

majority side seeking time for an opening statement? Members on

the minority side seeking time for an opening statement?

Seeing none, the chair then calls up H.R. 829, and asks the

clerk to report.

The Clerk. H.R. 829, to amend Title XIX of the Social

Security Act to clarify the treatment of lottery winnings and

other lump sum incomes for purposes of income eligibility under

the Medicaid program and for other purposes.

[The bill follows:]

**********INSERT 1**********

33


Mr. Burgess. Without objection, the first reading of the

bill is dispensed with and the bill will be open for amendment

at any point. So ordered. Are there bipartisan amendments to

the bill? Are there any other amendments to --

Mr. Upton. Mr. Chairman.

Mr. Burgess. For what purpose does the gentleman seek

recognition?

Mr. Upton. I have a technical amendment at the desk.

Mr. Burgess. The gentleman is recognized for five minutes

on his amendment.

Will the clerk report?

The Clerk. Amendment to H.R. 829 offered by Mr. Upton.

[The amendment of Mr. Upton follows:]

**********INSERT 2**********

34


Mr. Burgess. The gentleman is recognized for five minutes

on his amendment.

Mr. Upton. Well, thank you, Mr. Chairman. I referenced

this in my opening statement. This amendment makes some

technical improvements which were suggested by CMS. I would like

to think that it would be bipartisan as even those that are opposed

to the bill would probably support these technical amendments.

It allows more time for state implementation. It allows, but does

not require, a hardship exemption noting that a state can do that

through an 1115 waiver. It does not include, the technical

amendment does not include therefore striking, I guess you could

say, the special enrollment period in ACA which was in a previous

draft, so it clarifies that that is not included.

And lastly, it clarifies the winning test does apply to an

individual spouse. So again, it is a technical amendment. I

would like to think that it could pass by voice, and with that,

Mr. Chairman, I yield back the balance of my time.

Mr. Burgess. The gentleman yields back. The chair

recognizes the gentleman from Texas for five minutes. For what

purposes does the gentleman seek recognition?

Mr. Green. To oppose the amendment, Mr. Chairman.

Mr. Burgess. The gentleman is recognized for five minutes.

Mr. Green. Mr. Chairman, first of all, we have just seen

this amendment this morning, but what I look at is this first

35


section may be correct on what our Chairman Emeritus said. But

I think ultimately what this amendment does is make a bad bill

and makes it worse. It makes spousal winnings eligible for loss

of coverage for both spouses. It removes the counseling on

marketplace coverage upon loss of Medicaid. And it also further

adjusts the hardship exemption.

My colleagues have made a six-year career now to tear down

the Affordable Care Act marketplaces at every opportunity and they

never miss an opportunity no matter how small to sabotage the

coverage.

The amendment actually makes a bad bill worse and I do not

support the amendment. I yield back my time.


the gentleman. Are there other members seeking time on the

amendment?

Seeing none, if there is no further discussion the vote

occurs on the amendment.

All those in favor shall signify by saying aye.

All those opposed nay.

The ayes appear to have it and the amendment is agreed to.

Are there additional amendments to the bill? Seeing none,

the question now occurs on forwarding H.R. 829, as amended, to

the full committee.

All those in favor say aye.

36


All those opposed, no.

The ayes appear to have it.

For what purpose does the gentlelady seek recognition?

Ms. Eshoo. Can I move to strike the last word and ask some

questions of the legal counsel on the bill?

Mr. Burgess. I think we are on the question of approval of

the bill.

Mr. Pallone. Mr. Chairman, I would request a roll call vote.

Mr. Burgess. A roll call vote has been ordered. The clerk

will call the roll on the bill.

The Clerk. Mr. Guthrie.

(No response.)

The Clerk. Mr. Barton.

Mr. Barton. Aye.

The Clerk. Mr. Barton votes aye. Mr. Upton.

Mr. Upton. Aye.

The Clerk. Mr. Upton votes aye. Mr. Shimkus.

Mr. Shimkus. Aye.

The Clerk. Mr. Shimkus votes aye. Mr. Murphy.

Mr. Murphy. Aye.

The Clerk. Mr. Murphy votes aye. Mrs. Blackburn.

Mrs. Blackburn. Aye.

The Clerk. Mrs. Blackburn votes aye. Mrs. McMorris

Rodgers.

37


Mrs. McMorris Rodgers. Aye.

The Clerk. Mrs. McMorris Rodgers votes aye. Mr. Lance.

Mr. Lance. Aye.

The Clerk. Mr. Lance votes aye. Mr. Griffith.

Mr. Griffith. Aye.

The Clerk. Mr. Griffith votes aye. Mr. Bilirakis.

Mr. Bilirakis. Aye.

The Clerk. Mr. Bilirakis votes aye. Mr. long.

Mr. Long. Aye.

The Clerk. Mr. Long votes aye. Mr. Bucshon.

Mr. Bucshon. Aye.

The Clerk. Mr. Bucshon votes aye. Mrs. Brooks.

Mrs. Brooks. Aye.

The Clerk. Mrs. Brooks votes aye. Mr. Mullin.

Mr. Mullin. Aye.

The Clerk. Mr. Mullin votes aye. Mr. Hudson.

Mr. Hudson. Aye.

The Clerk. Mr. Hudson votes aye. Mr. Collins.

Mr. Collins. Aye.

The Clerk. Mr. Collins votes aye. Mr. Carter.

Mr. Carter. Aye.

The Clerk. Mr. Carter votes aye. Mr. Walden.

Mr. Walden. Aye.

The Clerk. Mr. Walden votes aye. Mr. Green.

38


Mr. Green. No.

The Clerk. Mr. Green votes no. Mr. Engel.

(No response.)

The Clerk. Ms. Schakowsky.

Ms. Schakowsky. No.

The Clerk. Ms. Schakowsky votes no. Mr. Butterfield.

(No response.)

The Clerk. Ms. Matsui.

Ms. Matsui. No.

The Clerk. Ms. Matsui votes no. Ms. Castor.

Ms. Castor. No.

The Clerk. Ms. Castor votes no. Mr. Sarbanes.

Mr. Sarbanes. No.

The Clerk. Mr. Sarbanes votes no. Mr. Lujan.

Mr. Lujan. No.

The Clerk. Mr. Lujan votes no. Mr. Schrader.

Mr. Schrader. Aye.

The Clerk. Mr. Schrader votes aye. Mr. Kennedy.

Mr. Kennedy. No.

The Clerk. Mr. Kennedy votes no. Mr. Cardenas.

(No response.)

The Clerk. Ms. Eshoo.

Ms. Eshoo. No.

The Clerk. Ms. Eshoo votes no. Ms. DeGette.

39


Ms. DeGette. No.

The Clerk. Ms. DeGette votes no. Mr. Pallone.

Mr. Pallone. No.

The Clerk. Mr. Pallone votes no. Chairman Burgess.

Mr. Burgess. Aye.

The Clerk. Chairman Burgess votes aye.

Mr. Burgess. How is the gentleman from Kentucky recorded?

The Clerk. He is not recorded.

Mr. Guthrie. I vote aye.

The Clerk. Mr. Guthrie votes aye.

Mr. Burgess. And how is the gentleman from North Carolina

recorded?

The Clerk. He is not recorded.

Mr. Butterfield. No.

The Clerk. Mr. Butterfield votes no.

Mr. Burgess. Are there other members seeking to vote? If

not, the clerk will report.

The Clerk. Mr. Chairman, on that vote, there are 20 ayes

and 12 nos.

Mr. Burgess. 20 ayes and 12 nos. The bill is agreed to and

reported to the committee.

For what purposes does the gentlelady from California seek

recognition?

Ms. Eshoo. Thank you, I move to strike the last word, Mr.

40


Chairman.

Mr. Burgess. The gentlelady is recognized for five minutes.

Ms. Eshoo. Thank you. I would like to ask the follow

questions of the Legal Counsel on the lottery bill. First, how

many lottery winners, above the threshold that is in the

legislation in the United States are enrolled in Medicaid?

Counsel. There is not a national survey. However, one

state that we have engaged with found 6,000 lottery winners who

were receiving, were part of the household receiving Medicaid.

And of that group, about 200 individuals had winnings of $20,000

or more.

Ms. Eshoo. How many in what state?

Counsel. That would be illustrative. Six thousand lottery

winners who were receiving or were part of a household receiving

Medicaid.

Ms. Eshoo. At the threshold and above?

Counsel. Sorry?

Ms. Eshoo. The threshold that is in the bill, $20,000.

Counsel. That would be individuals on Medicaid. We don't

have --

Ms. Eshoo. How many?

Counsel. National on how many would be above the threshold.

Ms. Eshoo. So you have no national numbers for a basis in

the bill? Because we don't know. I think that is what you are

41


telling me. You can't tell us how many lottery winners above the

threshold that is in the bill, across the country, are enrolled

in Medicaid?

Counsel. Well, as the chairman pointed out, and as you know

well, Medicaid data is challenging in its timeliness, accuracy,

and completeness.

Ms. Eshoo. It is also the responsibility of legislation to

have a foundational information from which to move from.

My next question is --

Mr. Upton. Will the gentlelady yield?

Mr. Burgess. Ms. Eshoo?

Ms. Eshoo. I will once I finish my questions. I would be

glad to, to whomever wants to say something.

Do states today have the flexibility to adjust for lump sum

payments?

Counsel. No.

Ms. Eshoo. Well, in the statute, CMS says that CMS requires

that enrollees notify the state Medicaid agency immediately if

they have a change of circumstance that affects their eligibility.

And CMS additionally requires that states annually redetermine

Medicaid eligibility as part of that process that states may adopt

a reasonable method to include a prorated portion of reasonably

predicted future income to account for increases or decreases in

future income.

42


So you are saying that there is not any flexibility on the

part of states today and that is why the bill mandates what it

mandates?

Counsel. The issue that the bill seeks to address is that

under the Affordable Care Act which mandated the use of modified

adjusted gross income for large portions of the Medicaid program,

certain populations, not all populations, that lump sum payments,

including lottery winnings, are only counted in the month that

they are received.

Ms. Eshoo. Is this bill scored?

Counsel. It is easier to be disenrolled from the program

--

Ms. Eshoo. Is this bill scored?

Counsel. This particular version, there have been, as you

know, multiple versions.

Ms. Eshoo. Has the bill been scored?

Counsel. Congress. So there are -- we have had --

Ms. Eshoo. You can just yes or no.

Counsel. We have had initial conversations with

Congressional Budget Office, but on various iterations.

Ms. Eshoo. Has it been scored?

Counsel. We have not requested an official scoring at this

time.

Ms. Eshoo. Now this was mentioned earlier. In the State

43


of Michigan in 2015, the total amount of garnishments collected

by lottery was $380.67. And I think that that is very important

to place on the record. I would welcome $380.67 in my checking

account, but I wouldn't consider that a standout. And that is

a major state in our country. So I think that the answers of the

counsel where there is not something foundational that tells us

what we are pursuing, how widespread is this, a major state in

the union in 2015, the total amount of garnishments collected by

a lottery was $380.67. I don't think the bill has been scored

and we really don't know how many people we are talking about in

the country above the threshold that is in the bill.

So if this is reform, I would say that it seems to be a pebble

in the sand in my view, because the counsel can't give me anything

meaty. So I will yield. Who wanted time?

Mr. Burgess. The chair thanks the gentlelady.

Ms. Eshoo. I only have a few seconds, so there is not that

much to yield. Thank you.

Mr. Burgess. The time is expired.

Mr. Upton. Mr. Chairman, strike the last word. And I know

we have already passed this.

Mr. Burgess. The gentleman from Michigan is recognized.

The chair does observe the bill has passed.

Mr. Upton. It has passed. I just want to briefly say a

couple of things. First of all, this gives the states the

44


authority to collect once those winnings are made which they don't

really have that ability today.

Second, I would note that in our long deliberation on the

21st Century Cures of which again I want to compliment every member

of this committee for their support, you will recall that we had

sizable sums for a variety of things including the Bo Biden

Moonshot, precision medicine, fight on opioids, more money for

the NIH. And one of the challenges that we had from the get go

was that we had to come up with pay-fors for all of that. And

actually, we had to come up with two sets of pay-fors because the

first set is what I say stolen by the Senate and we had to come

up with a second version.

One of the things that we talked about, but did not have

unanimous support on both sides of the aisle was money from states

where you had lottery winners. And there were some versions of

this bill that CBO did score that, as I recall, those numbers were

in the hundreds of millions of dollars that CBO gave us. Whereas

this bill was just introduced last week, CBO is a great

institution, but they often aren't able to turn around literally

within a couple of legislative days. I know that basically we

will get a score, but in fact, it was pointed out and not included

as part of the Cures bill, but hundreds of millions of dollars

is not a minimal amount that you ought to turn your back on. And

for those of us that want this program to be targeted towards the

45


most vulnerable and clearly it is, when you have pretty sizable

winnings I would guess that not a one of us would turn our back

on, $80,000 or more, that ought to be included as part of the

financial wherewithal of that individual or family that receives

it in that year that they received it. So I just want to make

that part of the record and I --

Mr. Walden. Would the gentleman yield?

Mr. Burgess. I yield to the gentleman of the full committee.

Mr. Walden. I thank the gentleman for clarifying because

that was further predicate for moving forward on this legislation.

We didn't anticipate that the opposition from the other side

against getting quote unquote bad actors out of the system, as

Mr. Green referred to them, would be so controversial, especially

when we had these scores showing hundreds of millions of dollars

in potential savings. And we circulated this morning and I think

this morning a draft amendment that may be in full committee we

can earn some bipartisan support for that would take those savings

that the only scores we have had from CBO indicated it was in the

hundreds of millions of dollars and target some of that toward

tobacco cessation benefits in Medicaid for moms with newborns.

See, this is about making choices between bad actors and

lottery winners and people with big lump sum payments and saving

money, cleaning up what we think is a loophole and putting that

money to a better purpose. So I would hope even though you have

46


described this, the Democrats have described this as not doing

anything or doing too much. I can't figure out which. On the

one hand you say it doesn't save anything. On the other hand you

say it destroys Medicaid, neither which are correct. I think we

should make some good choices here. We have that opportunity.

We are going to take these a step at a time, issue by issue,

and then we will see where people are. But let's do the right

thing for the American people. This saves hundreds of millions

of dollars potentially. We can help new moms to get off tobacco,

especially new moms with kids. Isn't that a better choice? I

think it is. That is what I hope we can build bipartisan support

for that amendment when we get to full committee.

I commend the gentleman from Michigan for bringing this issue

forward. This ought to be a no brainer and we are going to move

forward on it. Thank you. And I yield back the balance of your

time.

Mr. Upton. Mr. Chairman, I yield back the balance of my

time to Dr. Bucshon.

Mr. Bucshon. Yes, I just want to say briefly that since I

have been in Congress, no matter the subject, I have always heard

that a small amount of the taxpayer dollar isn't worth spending

in the appropriate way and that is how we have ended up $20 trillion

in debt and with large deficits. So the argument that small

dollar amounts, from my constituents that are not being spent

47


properly is not an argument that I agree with. And so I hope that

we move this through the full committee. I yield back.


the gentleman. The chair would observe that H.R. 829 has been

referred --

Mr. Pallone. Mr. Chairman.

Mr. Burgess. For what purpose does the gentleman from New

Jersey seek recognition?

Mr. Walden. Parliamentary inquiry, Mr. Chairman.

Mr. Burgess. The gentleman will state his parliamentary

inquiry?

Mr. Walden. Are we actually in a position where we can

strike the last word or do we not need to move into a bill or an

amendment to be able to do that? I am not trying to cut things

off, I am just trying to get us --

Mr. Pallone. Mr. Chairman, you already recognized to strike

the last word.

Mr. Walden. No, I actually was yielded to by Chairman Upton

and Ms. Eshoo was yielded five, so we are kind of at an even point

here.

Mr. Burgess. Technically, the chair would observe that

there is not an underlying item on which to strike the last word.

The subcommittee has passed H.R. 829 and referred it to the

committee. The chair at this point would like to call up H.R.

48


181.

Mr. Pallone. Mr. Chairman --

Mr. Barton. Parliamentary --

Mr. Pallone. Let's just strike the last word on the new

bill, I guess.

Mr. Burgess. Right.

Mr. Pallone. That is fine.

Mr. Barton. Parliamentary inquiry, Mr. Chairman.

Mr. Burgess. The gentleman will state his parliamentary

inquiry.

Mr. Barton. Are we starting a new tradition where we vote

on the bills and then we have the debate after we vote?

Mr. Pallone. Well, the problem, Mr. Chairman, is that Ms.

Eshoo asked a question as we --

Mr. Burgess. Parliamentary inquiry and the chair is

prepared to rule and the answer is yes, the chair calls up H.R.

181 if someone wishes to strike the last word, obviously they are

free to do that. But I would like to ask the clerk to report.

The Clerk. H.R. 181, to amend title XIX of the Social

Security Act to count portions of income from annuities of a

community spouse as income available to institutionalize spouses

for purposes of eligibility for medical assistance and for other

purposes.

[The bill follows:]

49


**********INSERT 3**********

50


Mr. Burgess. Without objection, the first reading of the

bill is dispensed with and the bill will be open for amendment

at any point. So ordered.

Are there bipartisan amendments to the bill? Are there

other amendments to the bill? Is there further discussion?

Mr. Pallone. Mr. Chairman?

Mr. Burgess. For what purpose does the gentleman from New

Jersey wish to be recognized?

Mr. Pallone. Strike the last word.


Mr. Pallone. Thank you, Mr. Chairman. Part of the problem

with both of these bills, in my opinion, and the argument I am

trying to make is that we have major issues here with regard to

the Republican efforts to repeal the ACA, possibly repeal the

Medicaid expansion in the context of that, and hearings where the

Republicans keep denigrating the Medicaid program.

Part of our problem here today is as Democrats is that we

feel that what is before us is rather trivial and we are trying

to get to the triviality, if there is such a word, by asking

questions of counsel.

My problem here is that I don't really think that Ms. Eshoo's

questions were answered. The chairman of the committee talked

about scoring. One of the things that she mentioned was that this

bill hadn't been scored and I understand the chairman saying a

51


previous similar bill had been scored, but it is not the same bill.

And so we are really questioning to what extent these bills

are doing anything meaningful. And I just wanted to ask the

counsel if I could a question which is Ms. Eshoo specifically asked

a question about the data that was the basis for the first bill

and you mentioned one state, but I didn't hear you mention which

state. And I would like to know which state you were referencing.

And also, it wasn't clear to me what you were saying. Were you

saying that there were several thousand people that were on

Medicaid in that state or were you saying that there were several

thousand people that won the lottery? And then you mentioned

another figure about 250 people. I didn't understand the

distinction.

So could you once again just reiterate to me what state were

you talking about and what were those two distinctions? One

figure was in the thousands and the other figure was like 250.

Counsel. So State of Michigan reported that they more than

6,000 lottery winners who were receiving or were part of a

household receiving Medicaid. And of this group about 200

individuals had winnings of $20,000 or more.

Mr. Pallone. Okay, and then she brought up the figure about

$300 and some dollars, the total amount of garnishments collected

by the lottery. Do you agree with that?

Counsel. Sir, I don't know report you are referring to, sir.

52


Mr. Pallone. Michigan health account garnishments

collected by the treasury.

Counsel. Right, so the State of Michigan was the state that

put this issue on the committee's radar because they have -- they

raised with us the case of an individual who won a significant

amount of money in the lottery that was still receiving services

under the Medicaid program that they were not allowed under

current law to disenroll.

I am happy to take a look at that report. You may, as you

know, garnishment may refer to the amount saved from other

programs. Of course, the amount garnished or the amount saved

would go up if this bill were passed because monies could be

counted differently than they are under current law today.

Mr. Pallone. All right, I appreciate your responding and

giving us the information that you were talking about the State

of Michigan and those details. But again, I really want to point

out that our concern here on our side is that these bills are

relatively trivial in my opinion in terms of the larger issues

of people being covered by Medicaid and the possible loss of

Medicaid expansion if the Affordable Care Act is repealed. And

I understand that the Republicans want to focus on this maybe

because it gets some media attention. But in the overall scheme

of things in Michigan and elsewhere, we are really not talking

about that many people. So thank you, Mr. Chairman.

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gentleman does yield back. The question now occurs --

Mr. Mullin. Can I move to strike the last word, please?

Mr. Burgess. Mr. Mullin, for what purpose does the

gentleman from Oklahoma seek recognition?

Mr. Mullin. I move to strike the last word.


Mr. Mullin. I know we are talking about trivial and making

a point. I come from a business background and I always had a saying

with our foremans and my officers of our company that if you watch

the pennies, the dollars will take care of themselves.

We have never claimed that this is going to fix everything,

but this is a starting point. Now anyone that wants to make the

argument that Medicaid is perfect and that it doesn't need some

repairs and it is completely affordable haven't been listening

to their states.

To say that we are trying to get media attention, that is

just the opposite. We are trying to actually do something. We

are trying to actually get something fixed. And instead, I am

hearing nothing but people wanting to grab sound bites and speak

off talking points and simply disrupt the hearing.

Now if you can make a legitimate argument, a legitimate

argument that is perfect and it doesn't need to be touched, then

try to do that. But don't come up here and just accuse us of doing

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everything underneath the sun. It needs help. It needs

attention. So if you got better ideas, let me know. If you have

got a better direction, let us know because ACA, affordable

healthcare, is broke. It is not affordable. And it is causing

states all across the country, blue and red states, to go bankrupt

and we are okay with just sitting there?

What is wrong with trying to come up with different ideas?

I don't understand it. I mean other than just sitting here and

taking it? Really, guys? Let's just move forward. Let's try

to come up with small, small problems that can be solved. These

two things should be something this committee can work together

on. I yield back.

Ms. Schakowsky. Move to strike the last word.

Mr. Green. Move to strike the last word.


gentleman yields back. For what purpose does the gentleman from

Texas seek recognition?

Mr. Green. Mr. Chair, I would like to ask for five minutes

and strike the last word.


Mr. Green. We are actually on H.R. 181. And although we

still have some questions about 829, but that will be dealt with.

To my colleague from Oklahoma who we worked together on a

lot of things except I always tell him I wish he would quick

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stealing our football players from Texas, but I don't think

anybody is defending that Medicaid is not perfect, because it is

not. And we know because at least in Texas and I don't know the

numbers in Oklahoma, but it is typically two-thirds federal

funding and a third state funding. And the states struggle with

it. In fact, I don't think the State of Texas is matching their

one third that is supposed to be done.

But what we are looking at, even though these may be not major

issues, but we ought to look at them in a whole and see -- and

not having a CBO score, it is not required until it gets to the

floor, but I think our committee would like to see, okay, let's

see what the numbers really are on this because if we are going

to do two bills today and maybe next week or a month from now do

a couple of bills, I would like to see them and I think everybody

one say what does it do to the whole program? And I don't think

any of us want to defend someone who gets -- wins $1 million or

over $80,000 that should be built in and the formula already is

built in, if there is a lump sum amount that was under the

Affordable Care Act to try and get that.

But I think that is why, Mr. Chairman, I know we don't have

to have one, but is there any possibility we can encourage the

CBO to give us a score that even anticipation of the bill getting

to the floor, so you and I would know what it is.

And on the 181, let me address to my colleague from Virginia,

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I actually practiced probate law in Texas and I am going to apply

for my CLE from the State of Texas because you explained to me

some of the things I hadn't thought about in years. But I think

there is a lot of things that may impact this depending on local

state law. Virginia is most different than Texas. And so I think

before we vote on this or at least before the full committee, we

should have a CBO estimate on both bills, but also have some of

the questions answered.

And I know there is an amendment on 181 that is not going

to be offered for pregnant women and substance abuse that is a

bipartisan -- I mean I think you would get bipartisan support,

but that doesn't make the bill good enough for us just on that

amendment, that it is a good amendment. And I will yield back.

Does somebody else want my time?

I yield my time to Congresswoman Schakowsky.

Ms. Schakowsky. I thank the gentleman for yielding. You

know, this is described as a step in the right direction. Yes,

exactly. Let's start with the spouses of somebody who has to go

into a nursing home that we are saying is going to make too much

money. So many of us have worked on the issue of spousal

impoverishment. And now we are talking about things like

$20,000. Oh, just wait until we get to the issues of reducing

corporate taxes, of reducing taxes overall, so that millionaires

and billionaires can get more money. That is not going to be a

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problem. But let's take a step in the right direction and start

with Medicaid recipients and let's start with the spouses of

people that need long-term care.

I just think this is so out of step with where ordinary

Americans are. Let's let those spouses, mostly women who

shouldn't get anything that their husband had or only half of it

in order to take care of their spouse that has some -- that has

Alzheimer's disease or some chronic terrible disease that they

can't handle by themselves.

I just think that this step is a step in the wrong direction,

going after the wrong people. And I am just really interested

when we get into talking about carried interests or other things

like that that affect the wealthiest Americans and we are going

to fiddle around with $20,000 here or $20,000 there for poor people

that in one month may use that money to pay down their debt or

that woman who wants to stay in the house, in the house that she

and her husband worked for. I think this is an inappropriate

discussion to start with or to end with and I yield back.

Mr. Burgess. The gentlelady yields back. Does the

gentleman yield back? The chair asks who seeks recognition?

Mr. Lujan. Mr. Chairman, strike the last word.


Mr. Lujan. Thank you, Mr. Chairman. Mr. Chairman, I think

that as we are having this conversation about shifting costs from

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the Federal Government to the states that we just be honest with

the American people what that means. If the Federal Government

is going to shift costs to the states, that means that the Federal

Government is reducing federal investments in the program. That

is what it means.

If, in fact, the Republican plan which would turn Medicaid

into a block grant program would take place, every state except

for North Dakota would experience dramatic cuts. That is a fact.

And we also know that again, according to some of the analysis

that has been done, the way that states will have to respond to

this is by cutting enrollment, limiting benefits, and reducing

payments to providers.

So as we have the conversation as to what is occurring with

this discussion and this debate, make no mistake this debate is

about cutting federal dollars to states. The Republican plan

would increase costs to states, unless the states dramatically

reduce their benefits. That is just what would happen here.

And as we talk about talking points, around the Affordable

Care Act, it has been incredible for me to see and witness how

the word replace has magically disappeared from the dictionaries

of our vocabulary that we use as tools and references.

Repeal and replace, repeal and replace, repeal and replace.

It was pounded across America. And now it is gone. And I have

had word changes. Well, the only person that continues to talk

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about repealing and his plan and is being honest at least with

the American people is the President. He continues to talk about

repeal, repeal, repeal. So again, let's just be honest with the

American people what these plans are about, what is going forward

here and again, let's find the ways that we can work together to

improve these programs without reducing benefits, without

increasing premiums, without increasing deductibles, without

decreasing access to care, without hurting our provider networks.

And that is where I hope we can be, Mr. Chairman.

I yield my time to Chairman Walden.

Mr. Walden. I thank the gentleman for yielding. I

appreciate his concerns. It is interesting, the governor of New

Mexico spokesperson said that she opposes Obamacare because it

hurts small businesses and raises premiums on our families. So

your own governor has a different view. She has seen what happens

in New Mexico.

My governor -- I think we both have governors that did

expansion. There are various views within our states certainly.

But a common view, even with my governor is that there are things

we need to fix and change to make this really work. This again

is just one -- this is a little clean up item, but it still could

be hundreds of millions of dollars between the two bills and we

could target that in to helping the most vulnerable and needy.

And that is the whole purpose. Gosh, this ought to be a simple,

60


bipartisan effort. I am sort of shocked at the opposition that

on the one hand says they are bad actors. We shouldn't waste our

time rooting them out. And that is what the ranking member of

the subcommittee seemed to allude to. And then turn around and

say if you are going to admit they are bad actors, why wouldn't

we root them out as Mr. Mullin said that we have got to close all

these little holes in the bucket. This stuff matters.

So whether it is your state or my state, there ought to be

common ground here that people who are millionaires and

billionaires, who win a lottery or get a big inheritance, that

that should be looked at because there is a limited amount of money

to help the others who really need it. And so it takes money away

from those. We have got people on waiting lists. But I yield

back and I appreciate the courtesy of my friend.

Mr. Lujan. Thank you, Mr. Chairman. And maybe the

committee can help our good governor of the State of New Mexico

understand that before the Affordable Care Act, New Mexico had

the highest uninsured rate in the country. We also know that the

benefits associated with helping small businesses make coverage

more affordable in our state is important. And I would also

appreciate it if our people could help our good governor in New

Mexico help get our unemployment levels in a little better

condition with the state of the economy in our great state. I

look forward to working with our colleagues from around the

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country to help get some more support back in New Mexico.

But make no mistake, if Governor Martinez supports this

program, Governor Martinez is supporting a 30 percent reduction

in Medicaid funding from the Federal Government to the State of

New Mexico and the State of New Mexico is already bursting at the

seams to try to figure out how to balance our budget. So if that

is where the governor's position is, I think that there is going

to be some more questions back home and I encourage the media to

ask for those questions back in New Mexico.

Mr. Burgess. The gentleman's time has expired. The chair

thanks the gentleman. For what purpose does the gentleman from

New York seek recognition?

Mr. Engel. I move to strike the last word.

Mr. Burgess. Strike the last word. The gentleman has five

minutes.

Mr. Engel. Thank you, Mr. Chairman. As we learned during

last week's hearing on Medicaid, my Republican friend's

suggestion that if states have high coverage levels, they are also

letting Americans suffer on waiting lists is really not true.

There is no evidence that refusing or holding up Americans'

Medicaid coverage, as these bills would do, would reduce waiting

lists for home and community-based services.

For having debunked that claim, it is clear that these bills

are just another facet of the GOP's plot to gut a program that

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serves roughly one in every five Americans. So we cannot be

fooled by these attempts to brand these bills as something they

are not. I oppose the bills before us today because I feel that

Republicans' proposals to delay or deny Medicaid coverage under

the guise of strengthening the program are untrue and misguided

and should be rejected. I thank you, Mr. Chair, and I yield back.


the gentleman. The question now occurs on forwarding H.R. 181

to the full committee.

All those in favor say aye.

Those opposed, no.

The ayes appear to have it. The ayes have it and the bill

is agreed to.

Mr. Green. Roll call.

Mr. Burgess. A roll call vote is requested. The clerk will

call the roll.

The Clerk. Mr. Guthrie.

Mr. Guthrie. Aye.

The Clerk. Mr. Guthrie votes aye. Mr. Barton.

Mr. Barton. Aye.

The Clerk. Mr. Barton votes aye. Mr. Upton.

Mr. Upton. Aye.

The Clerk. Mr. Upton votes aye. Mr. Shimkus.

Mr. Shimkus. Aye.

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The Clerk. Mr. Shimkus votes aye. Mr. Murphy.

Mr. Murphy. Aye.

The Clerk. Mr. Murphy votes aye. Mrs. Blackburn.

Mrs. Blackburn. Aye.

The Clerk. Mrs. Blackburn votes aye. Mrs. McMorris

Rodgers.

(No response.)

Mr. Lance.

Mr. Lance. Aye.

The Clerk. Mr. Lance votes aye. Mr. Griffith.

Mr. Griffith. Aye.

The Clerk. Mr. Griffith votes aye. Mr. Bilirakis.

Mr. Bilirakis. Aye.

The Clerk. Mr. Bilirakis votes aye. Mr. Long.

Mr. Long. Aye.

The Clerk. Mr. Long votes aye. Mr. Bucshon.

Mr. Bucshon. Aye.

The Clerk. Mr. Bucshon votes aye. Mrs. Brooks.

Mrs. Brooks. Aye.

The Clerk. Mrs. Brooks votes aye. Mr. Mullin.

Mr. Mullin. Aye.

The Clerk. Mr. Mullin votes aye. Mr. Hudson.

Mr. Hudson. Aye.

The Clerk. Mr. Hudson votes aye. Mr. Collins.

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Mr. Collins. Aye.

The Clerk. Mr. Collins votes aye. Mr. Carter.

Mr. Carter. Aye.

The Clerk. Mr. Carter votes aye. Mr. Walden.

Mr. Walden. Aye.

The Clerk. Mr. Walden votes aye. Mr. Green.

Mr. Green. No.

The Clerk. Mr. Green votes no. Mr. Engel.

Mr. Engel. No.

The Clerk. Mr. Engel votes no. Ms. Schakowsky.

Ms. Schakowsky. No.

The Clerk. Ms. Schakowsky votes no. Mr. Butterfield.

Mr. Butterfield. No.

The Clerk. Mr. Butterfield votes no. Ms. Matsui.

Ms. Matsui. No.

The Clerk. Ms. Matsui votes no. Ms. Castor.

(No response.)

The Clerk. Mr. Sarbanes.

Mr. Sarbanes. No.

The Clerk. Mr. Sarbanes votes no. Mr. Lujan.

Mr. Lujan. No.

The Clerk. Mr. Lujan votes no. Mr. Schrader.

Mr. Schrader. No.

The Clerk. Mr. Schrader votes no. Mr. Kennedy.

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Mr. Kennedy. No.

The Clerk. Mr. Kennedy votes no. Mr. Cardenas.

Mr. Cardenas. No.

The Clerk. Mr. Cardenas votes no. Ms. Eshoo.

Ms. Eshoo. No.

The Clerk. Ms. Eshoo votes no. Ms. DeGette.

Ms. DeGette. No.

The Clerk. Ms. DeGette votes no. Mr. Pallone.

Mr. Pallone. No.

The Clerk. Mr. Pallone votes no. Chairman Burgess.

Mr. Burgess. Aye.

The Clerk. Chairman Burgess votes aye. She is not

recorded.

Mrs. McMorris Rodgers. Aye.

The Clerk. Mrs. McMorris Rodgers votes aye.

Mr. Burgess. Are there any other members seeking to vote

on H.R. 181. If not, the clerk will report.

The Clerk. Mr. Chairman, on that vote there were 19 ayes,

and 13 nos.

Mr. Burgess. 19 ayes and 13 nos. The bill is agreed to and

forwarded to the full committee. Without objection, the staff

is authorized to make technical and conforming changes to the

legislation approved by the subcommittee today. Without

objection, the subcommittee is adjourned.

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[Whereupon, at 11:25 a.m., the subcommittee was adjourned.]

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